Maintaining readiness for validation surveys: How to be prepared when CMS surveyors come knocking

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How to be prepared when CMS surveyors come knocking


After reading this article, you will be able to:

  • Discuss differences in CMS and Joint Commission surveyor team makeup
  • Explain differences between Joint Commission and CMS survey styles
  • Identify specific areas the CMS team focused on during the surveys discussed

Reports from the field indicate that validation surveys by state surveyors on behalf of CMS—unannounced surveys used to validate an organization’s accreditation process—are happening with greater frequency this year.

These surveys are conducted on a representative sample basis or in response to substantial allegations of noncompliance. Unlike for-cause surveys, hospitals are selected randomly for validation surveys. It could be that CMS is requesting more validation surveys to be ready to review The Joint Commission’s soon-to-be-submitted applications for continued deeming authority.

One hospital, 30 outpatient practices

Central Maine Medical Center in Lewiston faced a slightly different challenge than the average hospital: The facility is a 250-bed hospital, but is interconnected with 30 outpatient practices as part of the hospital’s license.

“CMS goes to all sites,” says Patricia Roy, RN, MSN, CPHQ, director of professional quality services at Central Maine. “We had to have multiple surveyors out to every physical location we have.”

The five-day survey, which took place five weeks after the close of the Joint Commission (formerly JCAHO) survey, involved up to 11 surveyors each day.

“The [CMS] visit was a surprise. When they came to the door I thought, ‘You’ve got to be kidding!’ ” says Roy.

On the upside, however, the entire facility was still very much in survey mode.

“We still had binders we hadn’t put away from the Joint Commission visit,” says Roy. “As soon as they came in, we went right into response mode. They let us do an opening presentation, and we had it updated and ready.”

State to state

The surveyors did not arrive together as they would in a Joint Commission survey. “They sort of staggered in on the first day rather than arriving en masse,” says Roy. “The lead surveyor showed up first, then a few more, then we had the rest arrive a few hours later.”

This allowed additional time to get escorts ready for surveyors and to prepare staff members. The engineer surveyor arrived on day two, and the pharmacist surveyor arrived on day four.

“The amount of resources and people needed as opposed to a Joint Commission survey just to play host is quite a bit more,” says Roy. “Managers and directors always want to be back in their departments to help them get ready, but we really had to have eight or nine people playing host.”

With so many outpatient facilities, transportation was a unique problem. “Just to have enough people to drive them around was tough,” says Roy. “We had two fire marshals for all of the days as well, who also had to go to every physical site. It was an awful lot of traveling.”

To help keep things streamlined and organized in preparation for its most recent survey, Central Maine developed a command center concept. “This worked very well for us, so we did the same for the CMS survey,” says Roy.

Dedicated staff members served at the command center, passing out information to survey hosts and acting as the repository for requests coming in from staff members regarding what surveyors were looking for and which files they wanted.

“It helped us coordinate who was with who, where they were going, printing out the right schedules,” says Roy. “We had a managers’ briefing every night after the surveyors left with notes about what they were seeing, what their concerns were, so that the managers and staff could be prepared and calm.”

Roy found the focus varied between surveys.

“Compared to the Joint Commission survey, the CMS team focused tremendously on performance improvement and quality,” says Roy. “Hours and hours and hours spent discussing minutes, when did [a certain decision go] to the board, and details around one chapter of the regulations.”

15 surveyors, four days

For Norwood (MA) Hospital, the validation survey team arrived January 12, almost one month to the day following the hospital’s triannual Joint Commission survey. “We need to prepare our staffs for validation surveys because they seem to be occurring more frequently,” says Karen Reed, CPHQ, director of quality and safety at Norwood.

The validation survey featured many more surveyors than the Joint Commission survey, Reed says. Fifteen surveyors arrived at Norwood, including a mix of nurses, pharmacists, social workers, and nutritionists.

The survey took four days. Among the unique challenges of the CMS survey was the variability of surveyor hours. “Some of the surveyors work seven and a half hours, some work 10 hours,” says Reed.

As with the Central Maine survey, surveyors arrived at different hours of the morning, making it more challenging to ensure that all surveyors had escorts. A larger contingent of surveyors arriving at all hours created a different sort of logistical process than the standardized Joint Commission survey team.

Prep for electronic medical records

Hospitals with electronic medical records should plan ahead to address how surveyors will access these records, Reed says. At Norwood, surveyors reviewed records using a staff member’s password, with the staff member present to log in and monitor access. “We have asked our information technology group to investigate alternatives for access for regulators in the future,” says Reed. “Despite logistical considerations like these, the survey was considered a success. We felt really good by the time it was over.”

Reed says the biggest lesson of the validation survey is the need for continual survey readiness.



Adapted from Briefings on The Joint Commission, April 2009, HCPro, Inc.